While the management of patients with cardiac insufficiency with systolic dysfunction is well established , that of cardiac insufficiency with preserved ejection fraction is not based on any evidence. This is why – even though this pathology is present in more than 50% of patients with heart failure in clinical practice – only a minimal proportion of the latest European guidelines was devoted to this topic (one-quarter of a page within the 61 pages of recommendations and five of 270 references ). It also notably demonstrates the limits of the recommendations as well as the difficulty in writing the present paper, with its own limitations (it is a personal opinion and is therefore debatable).
The treatment philosophy for cardiac insufficiency with preserved systolic function is completely different from that of cardiac insufficiency with altered systolic function: with the latter, you want to block hormonal activation (RAS, sympathetic system); with the former you need to treat/address the causes of rigidity in the arteries and cardiac muscle (e.g. arterial hypertension), treat all comorbidities that could aggravate the symptoms of cardiac insufficiency, such as anaemia and renal insufficiency, and avoid the causes of acute cardiac decompensation (e.g. hypertensive crisis, infections, sodium overload, tachycardic episodes). Finally the treatment consists of maintaining the patient in euvolemia (emphasizing the importance of therapeutic education, diuretic treatment as a base if needed, avoiding dehydration, etc.), as outlined in Fig. 1 .
In the absence of a curative treatment for cardiac insufficiency with preserved systolic function, it makes sense to try to prevent its occurrence. However, in order to do so it is important to understand the causes of or factors responsible for this condition. This type of cardiac insufficiency is notably observed in hypertensive patients, diabetic patients, the elderly and in patients with renal insufficiency . We are able to treat diabetes and arterial hypertension and to slow the progression to cardiac insufficiency while it is still secondary to arterial hypertension and diabetes . The correct management of these pathologies before cardiac insufficiency occurs is therefore fundamental, although it is equally important after cardiac insufficiency appears in order to limit its progression or allow for a possible recovery (e.g. regression of cardiac muscle hypertrophy after stabilising blood pressure) .
The causal role played by arterial hypertension is fundamental: it is a factor in increasing arterial rigidity, cardiac hypertrophy and renal insufficiency. Treating arterial hypertension, even in the elderly, allows us to limit the appearance of cardiac insufficiency. The Hypertension in the Very Elderly Trial (HYVET) study, for example, demonstrated that the treatment of systolic arterial hypertension of more than 160 mmHg in patients over 80 years of age reduces the risk of cardiac insufficiency by 60% .
Even after the development of cardiac insufficiency, the treatment of arterial hypertension remains of utmost importance. This treatment is often challenging to put in place and its effects are difficult to evaluate due to the variability of blood pressure levels seen in such patients: the rigidity of their arteries, the reduction in sensitivity of baroreceptors, and systolic left ventricular function beyond the normal range allow rapid variations in blood pressure depending on both the position (orthostatic hypotension is frequent) and the effort being exerted (it is prudent to measure ambulatory arterial pressure in these patients to check that blood pressure is well controlled). The possibility of stenosis of the renal arteries should be considered or suspected in cases of persistent hypertension, the treatment of which sometimes results in stabilization of blood pressure, limits the progression of renal insufficiency and avoids the recurrence of pulmonary oedema, often secondary to a rapid increase in pressure (i.e. hypertensive crisis) . The choice of initial treatment for the management of hypertension is often determined by its tolerance : angiotensin-converting enzyme (ACE) inhibitors would be the first option in patients with altered renal function in order not to aggravate the condition; calcium channel blockers to counteract arterial rigidity (though it is still somewhat unrealistic to hope to dilate calcified arteries); beta-blockers to prevent any sudden rises in blood pressure associated with stress; and diuretics to limit or reduce hypervolemia, which is often present due to renal insufficiency or associated nephroangiosclerosis. In practice, our preference would be for ACE inhibitors as a first-line treatment, along with a mild diuretic (thiazide) and a beta-blocker in case of significant blood pressure lability.
Imagine that the arterial hypertension is controlled
If the patient is in atrial fibrillation – a frequent occurrence in this group of often hypertensive elderly patients – good control of cardiac rhythm must be ensured. Beta-blockers, which are also antihypertensive drugs, should be given as first-line treatment because they control both resting heart rate and heart rate on exertion, which digoxin does not . If either resting heart rate or heart rate on exertion remains high despite high doses of beta-blockers (which is rare), a heart-rate-lowering calcium channel blocker (which also treats arterial hypertension) could also be given, or even digoxin, provided renal function is compatible with its use. Experience shows that controlling cardiac rhythm is not easy to achieve in these patients, who often arrive as emergencies suffering from cardiac decompensation. If there is any doubt, Holter monitoring should be carried out to ensure that the resting heart rate as measured during the consultation accurately reflects heart rate throughout the day.
The problem can be more complex in patients with paroxysmal atrial fibrillation, who may have the beginning of bradycardia or tachycardia syndrome. Then, bradycardia may occur even at a low dose of beta-blockers, insufficient to lower heart rate during an episode of atrial fibrillation. These atrial fibrillation attacks may or may not be felt in the form of palpitations, and are therefore easy to miss if the clinician does not check carefully. The prescription of amiodarone may be justified to avoid such attacks, while remaining aware of the risk of bradycardia (and the risk of hyperthyroidism, which can also cause decompensation in patients with cardiac insufficiency and promote atrial fibrillation). If the episodes of atrial fibrillation are responsible for the cardiac decompensation and satisfactory medical treatment cannot be given, this may lead us to propose a pacemaker, allowing the introduction of a satisfactory anti-tachycardic treatment. Even paroxysmal atrial fibrillation justifies anticoagulant treatment .
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